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Prostate cancer an overview

Prostate cancer an overview

 

Dr. H Sanjay Bhat MS;DNB.FRCS.MCh (Urology)

Senior Consultant Urologist

Rajagiri Hospital, Alwaye,Kerala

What is the prostate gland?

The prostate gland is a walnut sized gland situated below the bladder in men, surrounding the urethra or tube which carries urine and semen out through the penis. Its main function is to add volume to the semen. It can be affected by infection, benign enlargement as a normal part of ageing or cancer.

                                                                                                                                                                                                            

How common is prostate cancer:

After 50 it is one of the most common cancers in men and may affect 1 in 7 men over all. The incidence increases with age but in general 1 in 14 men aged 65 and 1 in 5 men aged over 75 can have prostate cancer. It is a slow growing disease and many elderly men with prostate cancer may ultimately die of other age related illness rather than prostate cancer. Also this slow natural history makes it possible to provide long lasting cure when it is diagnosed and treated early.

Predisposing factors for prostate cancer:

Although the actual cause of prostate cancer is unknown it is well recognized that:

1: It is more common in USA and Africa. Even second generation immigrants to these countries have a higher risk implicating unknown environmental factors.

2: It is more common and aggressive in Black Americans, followed by whites, Asians and Indians have a low incidence and the lowest incidence is seen in Japanese men.

3: If a male relative has the disease the chance is doubled.

4: It is more common in people using diets rich in red meat(beef,pork,sausages,bacon,ham) as compared to vegetarian diets rich in green leafy and colored vegetables and fruits.

Myths:

It has no relationship with increased or decreased sexual activity and ejaculation !!!!.

Previous vasectomy does not increase the risk!!!!

Symptoms:

In early curable stages there may be no symptoms.

It can present as obstructive urinary symptoms such as hesitancy, poor stream, incomplete feeling of bladder emptying or complete blockage of urine.

It can present with irritative urinary symptoms like burning sensation, frequent urination, feeling of urgency to urinate or waking up frequently at night to pass urine.

When it spreads outside the prostate it can cause blockage of the tubes from the kidneys resulting in kidney failure, constipation and back or bone pain due to spread to the bones.

Hence a urological examination is mandated whenever these occur or once every 2 years from age 50 onwards.

 

When to screen for prostate cancer:

1: At age 50 and once in 2-3 years at least thereafter. (Although this is an individual choice).

2: It is mandatory if a male relative has been diagnosed previously.

3: African Americans.
4: If symptoms are present.
 

Stages of the disease:

Stage 1: Confined to less than half the gland. (Curable)

Stage 2: Involves more than half the gland but confined to its margins. (Curable)

Stage 3: Extends beyond the margins of the gland. ( Long term disease control is still possible)

Stage 4: Spread to distant organs like lymph glands, bone, liver,lungs.(Not curable but still better survival than other cancers of similar stage)

 

How to detect prostate cancer early:

Digital rectal examination(DRE): This involves insertion of a gloved , lubricated index finger into the rectum to feel the texture of the prostate for areas of hardness, bumps and mobility. This is the only internal organ so easily available for examination in men. It is quick and painless.


  

PSA Testing( prostate specific antigen):  This is a substance produced by the prostate gland cells and released into the blood circulation . It is usually present normally in small quantities (< 4ng/ml although this increases with normal ageing and the size of the gland). In cancer prostate cancer higher levels are seen.

# high psa levels warrant investigation
# serially increasing psa is worrying
# psa testing is useful to follow-up prostate cancer after treatment
 

                                                                                                                                                                                                                                                    

 

How to confirm the diagnosis:      

Once there is a strong suspicion on DRE and psa testing that a man may have prostate cancer one must proceed to confirm the diagnosis by BIOPSY testing.

TRUS Biopsy of the prostate (Transrectal ultrasound guided prostate biopsy) :

Under sedation or local anesthesia a specialized ultrasound probe is inserted into the rectum to image the prostate gland , study its appearance, target suspicious areas and accurately take mapping biopsies from multiple representative areas of the prostate to increase the detection rate. A specialized spring loaded needle is used for this purpose.



                                                                                                                                                                                                                                               

12 to 16 cores of tissue thus obtained are examined by an experienced pathologist who will make a diagnosis. The pathologist can further grade the tumor into 5 types to predict how aggressively it may behave.        

Once diagnosed what next:

If confirmed the next step is to stage the disease as discussed earlier. An MRI scan will reveal the local extent of the disease in and around the prostate.

 

                                                                                                                                                                                                                                    

An radioisotope bone scan will detect the spread if any to the bones.


                                                                                                                                                                                                                               

Picture on the left shows extensive spread of prostate cancer to most of the bones.
 
Treatment and out come:

Stage 1 and stage 2 and selected cases of stage 3 disease are treated with equal success by Radiation therapy, surgical excision or a combination of the two in selected patients. In general long term survival to the tune of 15 years to complete cure are obtained.

Radiation therapy

                                                                                                                                                                                     

 
 
3 D CT scan images of the prostate are fed into the radiotherapy unit to accurately deliver radiation to the prostate alone sparing surrounding organs. This reduces side effects. Treatment takes approximately 5 weeks and is usually done in combination with hormonal treatment
 
Usually for patients unfit for surgery or choosing this option . The results are comparable to surgery. Although rectal side effects like bloody and mucus diarrhea, erectile dysfunction and hormonal imbalances are reported. The prolonged nature of the treatment and its availability in select centers may also be a deciding factor. Ultimately the choice is left to the patient’s family.
Surgery:

Radical prostatectomy where the entire prostate gland, seminal vesicals and lymph glands are removed and the urinary passage reconstructed is the preferred option. This previously was performed by an open operation. Now with advancing technology it is performed by “key=hole” or laparoscopic and robotic assisted means. The pain, duration of hospitalization and time away from work are drastically reduced. The prolonged nature of radiation treatment , rectal side effects and hormonal imbalances are also avoided. Erectile dysfunction and temporaray stress induced urinary leakage are complications associated with this form of treatment but these can be overcome. Once again ultimately the patients family will decide on which option suits them as cure rates for both modalities is the same.

Other treatments:

In more advanced stages radiation therapy, hormonal treatments, chemotherapy and newer vaccines may be indicated. Charles Huggins received the Nobel Prize in Medicine for his startling discovery that prostate cancer cells are sustained by a constant supply of male hormone called testosterone produced by the testicles. He showed that removing the testicles (castration) produced regression of cancer. This formed the basis for hormonal treatment and now there are various drugs available to produce medical castration.  5 to 10 years of life span is still possible in more advanced stages of prostate cancer unlike the situation in other cancers of similar stage.

                     

                                                

Disclaimer: This is a simplified article on prostate cancer and is  by no means the final say. They are my personal opinions and are intended for an easy understanding by a general reader. More information may be obtained by consulting your urologist
 

 

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